Health Care Assiciated Infections and Antibiotic Resistance: an increasing threat to Patient Safety in Europe Aftab Jasir, European Centre for Disease Prevention and Control (ECDC)
European public health microbiology training program (EUPHEM)
Objectives of the lecture
To learn and understand about:
Basic of antibiotics and resistant among bacteria
Health care associated infections
Relevant terminologies
Story of glory
1945
Fleming, Florey and Chain
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Antibiotics
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Antimicrobial drugs
Natural antibiotics
Synthesized antibiotics
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Natural antibiotics
Penicillium notatum
Knowledg about killing
Do we need to use antibiotics for killing of pathogens?
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Hip replacement
Organ transplants
Cancer chemotherapy
Intensive care
Care of preterm babies
Modern medicine is not possible without effective antimicrobials
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TerminologyTerminologyAntisepticsAntiseptics
• Topical substances (e.g. Topical substances (e.g. skin) skin)
• e.g. iodine or 70% e.g. iodine or 70% alcoholalcohol• “ “reduce” bacterial loadreduce” bacterial load
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AntibioticsAntibiotics
• Selectively toxic for bacteriaSelectively toxic for bacteria• bactericidal (killing) bactericidal (killing) • bacteriostatic (growth inhibition)bacteriostatic (growth inhibition)
• no harm to patient (???)no harm to patient (???)
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Prophylaxis
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Minimal inhibitory concentration/ Minimal inhibitory concentration/ minimal bactericidal concentration minimal bactericidal concentration
(MIC/MBC)(MIC/MBC)
lowest level stopping lowest level stopping growth/killinggrowth/killing
e. g. zone of inhibition around a e. g. zone of inhibition around a diskdisk
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MIC/MBC
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Most important targets in bacteria 1. Attack bacterial cell wall synthesis.
2. Interfere with protein synthesis.
3. Interference with nucleic acid synthesis (RNA and DNA)
4. Inhibition of an essential metabolic pathway that exists in the bacterium but does not exist in the host
5. Membrane inhibition or disruption doesn't work too well because of the similarities
between and bacterial membranes.
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Drug usage = Drug resistance
Basis of Antibiotic Resistance
The antibiotic resistance is guided by Genomic changes
Spread of R plasmids or other genetic elements among the Bacteria
Do remember Antibiotics are used in veterinary medicine
The discovery of antibiotic resistance was discovered with spread of R plasmids from animal sources
Plasmids and Transposons
RTF
R determina
nt
Tn 8
Tn 10
Tn 9
Tn 21
Superbugs
Multi drug-resistantacquired non-susceptibility to at least one agent in three or more antimicrobial categoriesExtensively drug-resistantnon-susceptibility to at least one agent in all but two or fewer antimicrobial categoriesPandrug-resistance (PDR)non-susceptibility to all agents in all antimicrobial categories
Welcome to the hospital!Bugs are waiting for you!!!
NIIIIIICE! I am getting something good here
Terminology
Nosocomial • Traditional meaning “originating in hospital”
Hospital-acquired/associated
Healthcare-acquired/associated
HAI or NI or HCAI
Definition
An infection occurring in a patient/staff/visitor in a
healthcare facility not present or incubated at the
time of admission.
- includes infections that do not become apparent until after discharge and occupational infections among staff of the facility
Healthcare-associated infections
Community-acquired
infections
Antimicrobial resistance
Healthcare-associated infections, antimicro-bial resistance: Overlapping, but not identical
Antimicrobial resistance
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Burden of Healthcare-Associated Infections and Multidrug Resistance (preliminary estimate)
Healthcare-associated infections (HCAI)• approximately 4 million per year• approx. 37,000 directly attributable deaths
each year
Multidrug-resistant bacteria • approximately 1/2 of the deaths attributable to
HCAI
are due to the 7 most common multidrug-resistant bacteria
in the 4 main types of HCAI: bloodstream infection, pneumonia, skin and soft tissue infection, urinary tract infection
This is an underestimate!Source: Suetens C & Monnet DL, ECDC(preliminary estimate)
Risk factors
External/none host• Catheters and other
invasive devices• Surgeries• Invasive procedures• Antibiotic exposure• Inadequate staff and
overcrowding
Internal/Host • Extremes of age• Immune status• Illness severity• Comorbidities • Colonization status
New challenges
http://ecdc.europa.eu/en/publications/Publications/Forms/ECDC_DispForm.aspx?ID=740
Challenges in developing Case-Definitions for HAI
Assumptions: >48 or >72 hours after admission Not incubating at the time of admission Can manifest after discharge Acquired in healthcare setting
Use both clinical and lab criteria
Examples of potential for misclassificationCase 1 80 y.o. patient, multiple medical problems,
lives at home, visited by grandchildren who have colds
2 days later, admitted for hip fracture
4 days after admission she develops RSV (respiratory syncytial virus) pneumonia
What you think?
Examples of potential for misclassificationCase 2 55 y.o. patient, admitted for work-up and
management of chest pain, cared for by healthcare worker taking care of another patient who has MRSA
Discharged after 2 days in hospital
Develops an MRSA soft tissue infection 3 weeks later while in the community
What now???
Incubation periods
C.difficile unknown MRSA unknown VRE unknown Influenza 1-4 days RSV 2-8 days Norovirus 24-48 hours
Conclusions
There are always outbreaks going on at the hospitals. However they might not be detectable
Hospitals are a suitable place for outbreak investigation
It is not always easy to define the cases
Outbreaks agents circulating frequently. Therefore you need good microbiological evidence to confirm your cases.
Hands are the most common public transport of microorganisms
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18 Nove
mber 2
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